Flipping Med Ed

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To help medical students progress faster and find their calling in the field, two educators suggest moving content delivery out of the classroom may be the way to bring the students back in.

The plan, featured in the October edition of Academic Medicine, comes from Charles G. Prober, senior associate dean of medical education of the Stanford University School of Medicine, and Salman Khan, founder of the Khan Academy.

Khan and Prober present a three-step road map: First, identifying a core curriculum with concepts and lessons that can be taught through the kinds of short, focused video clips pioneered by the Khan Academy; then, changing static and poorly attended lectures into interactive sessions where students can practice that curriculum; and finally, letting students explore their passion -- from bioengineering to public health -- early on in their med school careers.

“I think the notion of meeting the learner where they are is really important,” said Prober, noting “the writing is on the wall” about the flipped classroom model -- assigning recorded lectures and reserving classroom time for hands-on activities -- in K-12 education. “I do believe that’s the future model."

The act of posting abbreviated lectures online is not a groundbreaking idea, nor is it a first for medical education. Sites like MEDtube and UndergroundMed have in recent years sprouted to give lecture-skipping med students more resources to learn the basic competencies needed to pass their introductory courses, but where Stanford and the Khan Academy differ is that they aim to address why students skip class in the first place. As the plan aims to transform medical school, where many experts say that the outstanding, well-educated students are just the cohort most likely to succeed with video delivery.

The partnership is headed by Rishi Desai, who leads the Khan Academy's medical and science initiatives and spends Tuesdays as a clinical instructor at Stanford.

“Like most med students, I never went to class,” Desai said. “It’s so silly that I spent thousands of dollars on tuition, and I learned it all myself anyway.”

Before he joined the partnership one year ago, Desai made “wave after wave of videos” in an attempt to catch Khan’s eye. Once hired, he immediately set to work creating videos starring Stanford’s best teachers and researchers.

“We tried that strategy, and it was incredibly hard,” Desai said. “We spent months trying to get faculty to make videos, and on the side, students were coming into this booth that Stanford had set up, and they were making great content.”

In response, Desai flipped the already-flipped model, making students the stars of the videos -- at least in the short term. The Khan Academy has partnered with the Association of American Medical Colleges to produce test prep for the revised Medical College Admission Test, due out in 2015. The resources, set to launch in a few weeks, will feature student-made videos, peer-reviewed by medical professors.

“The big issue now is scalability,” Desai said. “To cover medicine, you probably need on the order of thousands of videos.”

Which is where Khan and Prober’s roadmap fits in. For the last two years, Stanford has offered an applied biochemistry course that uses the flipped classroom model. The course has so far been successful at raising student participation and engagement.

“The course went from being mostly rated as poor to being mostly rated from good to excellent,” Prober said. “Attendance at lectures went from 20 percent to about over 90 percent in the optional interactive session. It was really pretty dramatic.”

Tina Cowan, who teaches the course this fall, said the poor evaluations from when the course featured traditional lectures meant student opinion had nowhere to go than up. "Flipping is hard," she said. "It’s more work to flip than to pull the lecture that you used last year out of the drawer."

Still, four in five students say they prefer the new format, although with an important caveat: The instructional videos and interactive sessions need to be done well. Desai warned that may be a sign their judgment is colored by the novelty of the new format.

“When you’re a med student, and you’ve seen awful, awful lectures day in and day out -- on a scale from 1 to 10, when you’re used to every lecture being a 1 or a 2 -- if someone offers you a 4, you’re going to be ecstatic,” Desai said. “These lectures, even as a good as they are, I sincerely believe they can be 100 times better.”

That sort of improvement can only come if instructors accept their role in the classroom will change, Desai and Prober said. That does not mean their role will become any less important, however.

“Essentially, the idea is that it’s quite the opposite,” Desai said. In one example, he said data gathered from how students interact with the course materials can be used to produce powerful analytics. In turn, instructors can tailor the in-person part of the course to address specific issues without waiting for students to raise their hands. “They no longer have to fly blind,” he said.

If the model proves successful at changing how students behavior, Prober suggested it could be expanded to cover continuing education for practicing physicians. Desai, meanwhile, said he can imagine doctors prescribing patients videos explaining their illnesses along with their pills.

For now, the experiment continues its early stages of one flipped classroom and MCAT test prep resources. “If this is the correct model, the first part is building that core body of knowledge. That’s no small trick,” Prober said. “It’s a movement that takes time, attention -- and we’re going to stumble.”